Healthcare Provider Details

I. General information

NPI: 1063939833
Provider Name (Legal Business Name): ANGELA M BYNDON-GREGORY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE
CERES CA
95307-4562
US

IV. Provider business mailing address

9614 N 11TH ST
TAMPA FL
33612-8106
US

V. Phone/Fax

Practice location:
  • Phone: 209-300-8800
  • Fax:
Mailing address:
  • Phone: 813-479-7952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95130537
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: